Vulvo-Rectal Fistula

From Violence During First Coition

The patient, a young woman of 22 years, presented herself at
the gynecological clinic of the Philadelphia Dispensary, with the
following history: Previous to her marriage, which took place
eighteen months ago, she had been a perfectly healthy woman. From
the first attempt at sexual intercourse with her husband, which
caused her to suffer such acute pain that she almost fainted, she
dates all her trouble. The sexual act was also followed by severe
haemorrhage, which persisted for a month; the passage of faeces
and flatus per vulvam was at once noticed. Every repetition of
the sexual act for the next two or three weeks was followed by
renewed bleeding, and even at the present time she suffers
severely during intercourse. The passage of the faecal matter
through the vulva gradually increased in degree until the rectum
was evacuated entirely through the vulva. There has been an
entire inability to retain flatus and faeces. Examination: The
finger on entering the vulva passes at once into the rectum
through a patulous opening of sufficient size to admit two
fingers. Inspection shows a perfectly intact crescentic hymen of
moderate thickness and rigidity, having a small anterior opening.
Immediately in front of its posterior attachment is an irregular
transverse tear, an inch and a half in its longest diameter, with
thickened and everted edges, extending backwards and upwards for
about one and one-half inches, exposing to view the mucous
membrane of the bowel. The vagina is small and has evidently
never been entered ... The case here reported is of especial
interest from the fact that the traumatism undoubtedly occurred
during first coition; from the virginal condition of the hymen
and from the long time during which sexual relations were
maintained under conditions which must have been disagreeable to
both husband and wife ...

But for the fact that the husband had been deprived of
his prepuce in infancy, thereby rendering the penis callous by
the exposure of the glans to the air, it is hardly possible that
he could have forced the organ through the flesh as he did,
without so much personal suffering as to compel him to desist.